Appeal a Denied Claim
Appealing a Denied Health Care Reimbursement Account Claim
If your claim for a benefit is denied, in whole or in part, you will be provided with the following information in writing within 30 days after receiving your initial claim, or 45 days in special situations:
- The reason for denial,
- The plan provisions that are the basis for denial,
- An explanation of what other material or information is needed and why it is needed, and
- An explanation of the claims review process and time limits for appealing the determination, your right to obtain information about those procedures, and the right to sue in federal court.
You have the right to request certain documentation, as required by the Employee Retirement Income Security Act of 1974 (ERISA), which was relied on in making the adverse determination. This will be provided to you free of charge upon request.
If an extension is necessary due to the need for additional information, you will be notified of the specific information needed. The claim determination will be made within 15 days from the receipt of your response.
If you disagree with the decision, you may request a review of the decision by notifying the claims administrator in writing within 180 days of the date you receive notice of the denial. First level appeals should be mailed to the following address:
WageWorks Claims Appeal Board
*Be sure to provide your Duke Unique ID if asked or prompted to provide your Social Security number.
You will be able to examine all the materials related to your claim, such as the plan's official documents. The claims administrator will decide on your appeal within 30 days of when it is received.
If you do not agree with this decision, you have the right to a second level appeal to the Plan Administrator. Request for second level appeals should be sent to:
Reimbursement Account Plan Administrator
705 Broad Street
Durham, NC 27708
The Plan Administrator will decide on your appeal within 30 days of your second level appeal request.
If any of these claim deadlines falls on a Saturday, Sunday, or holiday, the deadline is postponed until the next business day. The Plan Administrator's decision on your appeal is final and conclusive.
If you are dissatisfied with the Plan Administrator's decision after you have pursued these steps, you have the right to file a lawsuit in a state or federal court. You may not file a lawsuit before 90 days have passed after you file your claim or later than three years after the event for which the claim was made occurred.